A secondary case of encopresis: Nautilus pompilius

by Jean-Jacques Demarteau

Young
Theo, 10 years old,
comes to the consultation for secondary
encopresis, with a
background of respiratory allergies. His constipation
is described as 'chronic' and
has not been treated medically, except of course for the 'accidents' that lead to the consultation.Theo
is two years older than his brother, who is fine and who shines at conversations and games in comparison
to him. Their mother has recently separated from
their father (barely a year
ago), and remodeled the new apartment with one bedroom for each boy.Theo
arrives with his mother, wondering what will happen during the interview. He talks about the fear of soiling himself at bedtime, which
prevents him from accepting invitations to sleep at his buddies’ place. This is
the classic situation, with shame being the major obstacle to realising social
situations.

After listening to the present complaints, I oriented the
interview towards the birth.

How was the birth?

"It
lasted 5 hours; Theo
did not come out and was
stuck at the level of the rib cage. I was so scared of losing him, afraid that
he could not survive
and breathe. Theo was finally born with mild cyanosis, but ultimately
without major setbacks;
however, I remember this episode of respiratory distress while transiting the cervix.”

Childhood diseases and mandatory vaccinations seem to have
not played a major role in his problems.

Theo is attentive and very awake,
with unconcealed curiosity about
what is happening.

When did
the first involuntary stools
begin?

"Just after the departure of their father, and always
in the same conditions. When Theo leaves his room to come into the living room,
there is a certain eagerness.
He is playing with his brother or alone; it's at this point that the disaster happens."

I speak directly to Theo, while asking him to clarify his feelings at that time, and
especially to see if there are other times when this kind of ‘poo accident’ occurs.

Do you agree with what your mom
described? Has
that happened to you in other circumstances?

" Well, not at the beginning, but now when I have a
bad grade at school or
when I'm bothered by my
friends, this happens more easily and more often, but I always feel it when I go out of my room.”

Does it
prevent you to sleep at
your buddies’s place
then? Has it ever happened on these occasions?

"Now, I'm afraid that it will happens at their home too, and I'd
be too ashamed. I would
not know how to wash and hide it all."

Has it already happened?

"No..."

This behavior seems to be confined to the small territory
of his room, so I ask him to describe his room.

The description does not elicit any useful information for
finding a remedy, nor do the gestures or words. I therefore propose Theo to
draw me a map of his room.

The picture
is a little small, since he
is slightly myopic, like his mother. One detail nevertheless attracted my attention: the positioning of the door on the
sketch.

I then create a little role play with Theo. I bring him to
the door of my office and ask him to go in and out, crossing the threshold,
either pushing the door or pulling it towards him. I asked him to select the
version which is identical with his own bedroom door. When he identified the
situation of the door that was like his bedroom, I asked him to make another
drawing to represent the sensation he feels when crossing the threshold.

On the initial doodle, there are no arrows, however, the door is clearly positioned.

After asking him to place himself somewhere (the circle with the cross), he
spontaneously describes
ways to leave this
space,
using arrows.

Meanwhile, he accompanies his drawings with sighs, and the
feeling of confinement and panic at seeking an exit are clear (as in
respiratory allergies, allergy to dust or acari that occupy the space of
security, making it "stifling").

My consultation then continues with a conversation with the mother and the child about the values that
are usually brought by
the father. After this explanation, which allows the mother and the child to be
aware of the elements that could be missing in the lives of children between 0
and 7 years, I offer a synthetic summary schema, drawn from my Lego Anatomy
courses.

This schema,
which serves as visual prop,
is an allegory that I created a few years ago. It probably stems from my past as a biologist.

I then asked Theo to make a list of the
values listed in the diagram, and mention those he considers to have received from his
father. Spontaneously, he
produces the next drawing (figure 3). He understands the concepts that have been given to him and now belong to him,
but also those with which
he has difficulty. The boxes
with a tick, such as “name”, are ones that he feels are a valid part of his
life, whereas the boxes with a cross represent ones he feels he is
missing. One can analyze the strength of the line according to the
checkboxes.

The right part of the drawing came spontaneously, a free interpretation of the
image with the test tube (everybody has recognized a test tube!).

It is the latter, and especially his interpretation of it, that will make the
link between the first doodles, and allow me to choose the remedy.

Can you talk to me a little bit about this little guy on the right side
of your drawing?

“It is me, of course!I'm in your tube, I can't get out. Then I use a tool to drill
glass and be able to get out in the open air, like burglars do.”

Analysis

After the first doodles, and in particular that of figure
1, I start searching in
the mineral world (structured design, symmetry elements, precision in details).
On reviewing figure 2, and especially
the design of synthesis of figure 3, I'm leaning towards the mineral component of an animal, or an animal whose
Anatomy is made of mineral features.

Figure 2 already makes me think of an ammonite, or a marine
animal fossil, a shellfish for example.

In zoology, the ‘test’ is a
covering made of mineral substance of limestone and silica, chitinous or
composite, whose
function is to serve as a protection for certain
animals, such as diatoms, sea urchins and
mollusks. In sea urchins,
this envelop has the name 'test', and is usually called "a sea urchin
test". In diatoms, it has
the name of frustule. In
molluscs, it is called the
shell.

The term
‘test’ comes from the Latin
"testa" which means 'hard shell '. This term has also formed the word
'head' in the meaning of skull. Have you
noticed the perfect correspondence between the head of the child and the
opening?

In figure 3, the outdoor activities remind me that the
door is a major element in the occurrence of the main symptom.

The opening to provide more space, more air, can
immediately imply a
relationship with allergies or breathing difficulties (sighs).

Rubrics:

- Closes the door to his friends,
feeling of confinement, concern for his house (Nat-phos).

- Wants an open door towards the
other, interpersonal communication that never fails, refuses the conventions of
human language (Aeth.).

- Hits
at the doors, wants
access to something. Opens
them up without knowing what he is seeking (Crot-ca.).

- Wants the doors closed, is sure that the known world is full, does not see what it lacks (Vip.).

Analysis (continued):

From the drawing of figure 4, things come alive a little
more and after thinking
about Silicea or Diamond (cut glass), I look for a gas (Oxygen), or an animal that expels gases through
an opening, if possible of a
rounded shape.

After having made my decision, out of curiosity, I asked
Theo what his second drawing reminds him of. "A
fossil, you know, with small boxes, this animal which enlarges his house when
it gets bigger!"

Follow-up

Two months later: the constipation is resolved and there
are no more accidents of soiling himself. Theo occasionally sleeps in his
friend’s home. Relationship with his younger brother is more peaceful, and Theo
expresses himself more easily, taking his place as the elder sibling. He asked
to change his room planning and now feels safe with the position of the door.
Allergic episodes appear to be much less frequent.

One year: he speaks more easily and feels much better away from
home. The initial symptoms have completely disappeared. The relationship with
his father has become easier, and the trust between father and
son is restored. The mother then came for herself, telling of some episodes of confinement
when she was a child. She had
good results from a single dose of Sepia, including her situation with her
children.